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Treatment of social phobiaDavid VealeAdv. Psychiatr. Treat. 2003 9: 258-264Access the most recent version at doi:10.1192/a...
Veale                                                      Advances in Psychiatric Treatment (2003), vol. 9, 258–264Treatm...
Treatment of social phobiaPsychopathology                                            sensations as evidence of an immediat...
Vealefools of themselves after excessive alcohol consump-        affected individual’s own evaluation of his or hertion. A...
Treatment of social phobiaindividuals believe that they are in danger of             aim is to understand the development ...
Vealeare elicited and of whether it takes an observer            first, getting insight in attentional processes and thepe...
Treatment of social phobiaModifying post-interaction ruminations                    dose can include sedation, forgetfulne...
VealeMarks, I. M. & Mathews, A. M. (2002) Brief standard self-         c the aim of video feedback is to demonstrate that ...
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Treatment of social phobia


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Treatment of social phobia

  1. 1. Treatment of social phobiaDavid VealeAdv. Psychiatr. Treat. 2003 9: 258-264Access the most recent version at doi:10.1192/apt.9.4.258 Reprints/ To obtain reprints or permission to reproduce material from this paper, please write permissions to can respond to this article at Email alerting Receive free email alerts when new articles cite this article - sign up in the box at the service top right corner of the article or click here Downloaded on April 7, 2011 from Published by The Royal College of PsychiatristsTo subscribe to Advances in Psychiatric Treatment go to:
  2. 2. Veale Advances in Psychiatric Treatment (2003), vol. 9, 258–264Treatment of social phobiaDavid Veale Abstract Social phobia (or social anxiety disorder) manifests as a marked and persistent fear of negative evaluation in social or performance situations.The epidemiology, diagnosis and psychopathology are reviewed, including clinical presentation, cultural aspects and the differences between agoraphobia and social phobia. Behavioural treatments, including graded self-exposure and cognitive restructuring, are considered. A cognitive model of the maintenance of social phobia is discussed. It is hypothesised that attentional shifting towards imagery, safety behaviours and ‘post-mortem’ analyses play a key role in symptom maintenance. The implications of this for treatment are described, and guidelines for pharmacological treatment are summarised.Social phobia (or social anxiety disorder) consists alcohol or substance misuse or body dysmorphicof a marked and persistent fear of social or disorder. In body dysmorphic disorder, patients areperformance situations. Affected individuals fear often too ashamed to reveal their preoccupation withthat they will be evaluated negatively or that they their appearance, and present with symptoms ofwill act in a humiliating or embarrassing way. social anxiety and depression, fearing that theExposure to social or performance situations mental health professional will view them as vaininvariably leads to panic or marked anxiety, and or narcissistic. A similar situation exists in patientssuch situations therefore tend to be avoided or with olfactory reference syndrome, who believeendured with extreme distress. that they have body odour that others will find Social phobia is the third most common mental unpleasant, which they may camouflage withdisorder in adults worldwide, with a lifetime perfume. Therefore, all patients with symptoms ofprevalence of at least 5% (depending on the social anxiety should be routinely asked whetherthreshold for distress and impairment). There is they are very concerned about some aspect of theiran equal gender ratio in treatment settings, but appearance or about body odour. It should bein catchment area surveys, there is a female pre- emphasised that patients with social phobia do notponderance of 3:2. Individuals are more likely to lack social skills. Most affected individuals will havebe unmarried and have a lower socio-economic normal social skills in a consultation with you, orstatus. Although common, social phobia is often not with a friend or partner. In social situations, theydiagnosed or effectively treated. There have, are trying too hard and can appear to lack socialhowever, been a number of developments in our skills, because they might interact less, keep theirunderstanding and treatment of social phobia over head down or not reveal personal information.the past decade, and these are the focus of this Patients (for example, those with Asperger syn-article. drome) who do lack communication skills have a different problem. The presentation of social phobia can depend onPresentation cultural contexts. In Western cultures, patients might present to surgeons for cures for complaints ofThe onset of social phobia usually takes place excessive blushing or sweating. In Japan, socialduring adolescence, although a minority of causes phobia is manifested as an extreme fear of bringinginvolve a late onset after a significant life event (such offence to others, and is referred to as taijin an episode of failure). The typical course is Sufferers of this disorder may fear that makingchronic and life-long. Predisposing factors include eye contact, blushing, imagined defects in theira shy or anxious temperament from childhood. There appearance or their body odour would be offensiveis significant comorbidity, especially of depression, to others.David Veale is an honorary senior lecturer at the Royal Free and University College Medical School and a consultant psychiatristat the Priory Hospital (The Bourne, Southgate, London N14 6RA, UK). He has a special interest in cognitive–behaviouraltherapy and its application to anxiety disorders and body dysmorphic disorder.258 Advances in Psychiatric Treatment (2003), vol. 9.
  3. 3. Treatment of social phobiaPsychopathology sensations as evidence of an immediate catastrophe to their health. Panic attacks in agoraphobia tend toThe core psychopathology in social phobia is a fear be both situational and spontaneous. Affectedof negative evaluation in social and performance individuals are concerned with a wider range ofsituations. It overlaps with the concept of shame, autonomic sensations such as palpitations andalthough the two sets of literature have largely feeling dizzy or short of breath. Those with socialignored one other (Gilbert & Andrews, 1998). Social phobia, however, are more likely to be concernedanxiety is best described as the fear of feeling with autonomic sensations of blushing, shaking orashamed (e.g. of the emotions aroused and their stammering (which the person believes may beinterference in one’s presentation) or the fear of being noticeable to others). Panic attacks in social phobiashamed (e.g. by the negative evaluation of oneself occur almost exclusively in social situations. Some-and potential loss of rank), or both. times, a patient with agoraphobia also has comorbid Social phobia usually leads to avoidance of symptoms of social anxiety. For example, he mightsituations such as public speaking or talking to a believe that he will collapse or go mad as a result ofgroup, parties, meetings, eating or drinking in a panic attack, but in a social situation, he mightpublic, working or writing while being observed, also fear causing a scene and others evaluating himtelephone calls, intimacy or dating. Groups are negatively. Typical beliefs in an individual withnearly always more anxiety-provoking than is an social phobia focus on the perceived negativeindividual. Peers of the same age are usually more evaluation by others of revealing a flaw or un-anxiety-provoking than older individuals. For acceptable behaviour (for example, the personheterosexual individuals, people of the opposite believes that her hands will shake or she will soundgender are usually more anxiety-provoking than stupid or boring). This is also referred to in thethose of the same gender. Sometimes individuals in literature as ‘external shame’.authority, especially at work, are more anxiety- Such individuals tend to have high standards orprovoking than individuals at the same level. rules about how they must perform in social There tend to be two sub-types of social phobia – situations. Their assumption is that failing togeneralised and non-generalised. Generalised social achieve these standards might lead others to seephobia is more disabling and involves a more diverse them as inferior, flawed or inadequate and they them-range of feared stimuli. Those affected by it include selves also agree with this assessment (referred tosome patients with avoidant personality disorder as ‘internal shame’). They predict that this failureand it has a worse prognosis. Non-generalised will lead to rejection or a further failure to achievesocial phobia is associated with avoidance of a an important goal. Individuals with no internallimited range of performance situations or inter- shame may know that others are rejecting them andactions (such as public speaking), and this overlaps view them as inferior, but not believe it aboutwith performance anxiety in sexual dysfunction. themselves.Non-generalised social phobia is easier to treat, with The emotions in social phobia are predominantlya better prognosis. those of anxiety and shame, and sometimes self- A person afraid of speaking in public would not disgust or anger (which will depend on beliefs andreceive a diagnosis of social phobia if public safety behaviours). As in other anxiety disorders,speaking was not routinely encountered and the the main coping (or defensive) behaviour is to escapeperson was not particularly distressed about it. It is from the situation. There is a strong urge not to beusually the degree of distress or impairment that seen. Eye gaze is commonly averted and there iswarrants a diagnosis of social phobia, and the behavioural inhibition (discussed in more detailpossible indicators need to be considered in the below under ‘safety behaviours’). These behav-appropriate context. For example, transient or mild iours might be linked to the submissive defensivesocial anxiety is especially common in adolescence. behaviours used to reduce aggression in anotherThe degree of severity in social phobia is very person in response to the threat of rejection.variable, ranging from individuals who are virtually When the focus is on another person as being badhousebound and have never had a relationship, to and doing something to expose the individual asothers who are highly functioning except in certain inferior, then the main emotion is of humiliationareas such as making a presentation, which they (rather than social anxiety). There is a sense offind very distressing and which handicaps them in injustice and unfairness, often leading to anger andtheir occupation. a strong desire for revenge against the one who is Social phobia might be confused with agora- exposing the self as weak or inferior.phobia. Individuals with agoraphobia tend to Alcohol and other substances are commonly usedbe female and to be anxious about their physical in social phobia, but such usage might result in aor mental health. They misinterpret physical self-fulfilling prophecy as patients may indeed makeAdvances in Psychiatric Treatment (2003), vol. 9. 259
  4. 4. Vealefools of themselves after excessive alcohol consump- affected individual’s own evaluation of his or hertion. Although alcohol and substance dependence behaviour that is crucial in determining the degreeneed to be treated first, many such patients will of social anxiety. Such alternative approaches arehave difficulty attending self-help groups such as not usually recommended, as adherence is likely toAlcoholics Anonymous. Nevertheless, mental health be poor unless the therapist is prepared to modelpractitioners who treat alcohol and substance the behaviour. Self-exposure and variants ofmisuse frequently fail to address the comorbid social cognitive restructuring are effective and validanxiety once the patient has stopped misusing and treatments, but the treatment gains might only berelapse is therefore common. modest. For example, Heimberg et al (1990) report that only 65% make ‘clinically significant change’.Assessment measures Cognitive therapySuitable assessment measures include the BriefSocial Phobia Scale (Davidson et al, 1991) and the Clark & Wells (1995) and Clark (2001) haveSocial Anxiety Scale (Liebowitz, 2002), which are developed a cognitive model for the maintenance ofboth observer-rated. Subjective rating scales include social phobia (Fig. 1). Most of the material for thethe Social Phobia and Anxiety Scale (Turner & rest of this article is derived from their approach.Beidel, 1989), the Social Phobia Inventory (Connor The aim of the model is to answer the question ofet al, 2000) and the Fear Questionnaire (Marks why the fears of someone with social phobia are& Mathews, 2002). maintained despite frequent exposure to social or public situations and the non-occurrence of the feared catastrophes. Recent research from controlledGraded self-exposure trials supports the efficacy of the approach (Clark et al, 2003). The model suggests that when patientsLearning theory hypothesises that avoidance enter a social situation, certain rules (e.g. ‘I mustmaintains the fear in social phobia, as patients are always appear witty and intelligent’), assumptionsmotivated to avoid ‘punishment’ by others. The (e.g. ‘If a woman really gets to know me then sheanticipated ‘punishment’ – the prediction of will think I am worthless’) or unconditional beliefsrejection, deflation and isolation – is never dis- (e.g. ‘I’m weird and boring’) are activated. Whenconfirmed. Graded self-exposure has been thetreatment of choice for social phobia for many years.A detailed hierarchy is made of all the situations Social situationthat the person avoids, with a rating of 0 to 100%according to the degree of anticipated anxiety. Self-exposure involves repeatedly facing previouslyavoided situations in a graded manner until Activates assumptionhabituation has occurred. There are problems with exposure alone – forexample, tasks might be brief (and not long enoughfor the anxiety to subside) or not susceptible to Perceived social dangerregular repetition. Furthermore, a significant numberof patients refuse self-exposure or drop out early. Ofthose who complete treatment, about 50% willovercome their problem. Treatment failures tend to Processingbe associated with a depressed mood, avoidant of self as a socialpersonality, intolerance of emotion and marked objectavoidance behaviour. Alternative approaches haveincluded group cognitive–behavioural therapy(Heimberg et al, 1990) or the addition of coping skills,cognitive restructuring or shame-attacking from Safety Somatic andrational emotive behaviour therapy. An example of behaviours cognitive symptomsshame-attacking is for the patient to shout out thenames of stations on a railway line. Other passengersmight think that the individual is stupid, but he orshe can learn that performing a stupid act does not Fig. 1 A model of social phobia.make one stupid ‘through and through’. It is the260 Advances in Psychiatric Treatment (2003), vol. 9.
  5. 5. Treatment of social phobiaindividuals believe that they are in danger of aim is to understand the development and main-negative evaluation, an attentional shift occurs tenance of the disorder and how the patient’s currenttowards detailed self-observation, and monitoring beliefs, emotions and behaviour interact. Sessionsof sensations and images. Socially anxious indivi- are recorded on audio- or videocassette so that theduals thus use internal information to infer how patient may listen to a session again and provideothers are evaluating them (in Fig. 1 this is feedback at the next session. The therapist also has‘processing of self as a social object’). The internal an opportunity of reviewing the sessions ininformation is associated with feeling anxious, and supervision.vivid or distorted images are imagined from an An idiosyncratic version of the model (Fig. 1) isobserver perspective (Hackmann et al, 2000). These drawn up with the patient, based upon a review ofimages are mostly visual, but they might also include recent episodes of social anxiety. First, the therapistbodily sensations and auditory or olfactory identifies a specific and recent social situation thatperspectives. This is not, of course, what an observer was sufficiently anxiety-provoking. He or she thenactually ‘sees’. Recurrent images can be elicited by attempts to identify the negative automatic thoughtsasking patients to recall a social situation associated by asking questions such as: ‘What went throughwith extreme anxiety. The images are usually linked your mind as you noticed yourself becomingto early memories. The therapist asks the patient anxious’, ‘What was the worst you thought couldwhen he or she remembers first having the experience happen?’ and ‘What did you suppose that othersencapsulated in the recurrent image and to recall would notice or think?’the sensory features and meaning that these had. The therapist may use a ‘downward arrow’For example, someone who had an image of being technique to try to identify the patients’ assumptionsfat remembered being teased during adolescence, and core beliefs. This involves asking the patient towhich resulted at the time in feelings of humiliation assume the worst and then to assume that theand rejection. thought is true. The therapist then asks what the A second factor that maintains symptoms of social most anxiety-provoking thing about the thought isphobia are safety behaviours. These are actions taken or what it means to the individual. For example:in feared situations which are designed to prevent Therapist: How did you feel you came across?feared catastrophes (Salkovskis, 1991). Safety Patient: I felt I appeared very red and soundedbehaviours in social phobia include: using alcohol; stupid.avoiding eye contact; gripping a glass too tightly; Therapist: Let’s assume that you did appear very redexcessive rehearsing of a presentation; reluctance and sounded stupid, what would that meanto reveal personal information; and asking many about you?questions. Safety behaviours are often problematic: Patient: I felt that I looked like an idiot and othersthey prevent disconfirmation of the feared catas- would be secretly laughing at me.trophe; they can heighten self-focused attention and Therapist: Let’s assume it’s true that everyone in themonitoring to determine if the behaviour is room is laughing to themselves, what would that mean to you?‘working’; they increase the feared symptoms (e.g., Patient: I think no one will really want to know mekeeping arms close to the body to stop others seeing in the future and I’ll be sweat will increase sweating); they have aneffect on others (e.g. the individual may appear cold Next, the therapist identifies the autonomicand unfriendly, so that a feared catastrophe becomes sensations or symptoms of anxiety by askinga self-fulfilling prophecy); and they can draw questions such as: ‘When you thought the fearedattention to feared symptoms (e.g. speaking quietly event might happen, what did you notice happeningand slowly will lead others to focus on the indi- in your body?’ (e.g. blushing, shaking, sweating).vidual even more). Safety behaviours are next elicited by asking It is hypothesised that a third factor that main- ‘When you thought the feared event might happen,tains symptoms of social phobia is anticipatory and did you do anything to try to prevent it frompost-event processing. Such processing focuses on happening?’, ‘Is there anything you do to try tothe feelings and constructed images of the self in the ensure you come across well?’ or ‘Do you doevent and leads to selective retrieval of past failures. anything to stop drawing attention to yourself?’ Increased self-consciousness and imagery are elicited by asking questions such as: ‘What happensStages of therapy to your attention when you are most afraid? Do you become more self-conscious? Do you haveTherapy begins with a detailed assessment and difficulty following what others are saying? Do youformulation of the problem, which is developed have a picture in your mind of how you feel youcollaboratively between therapist and patient. The are coming across?’ Further details of the imageryAdvances in Psychiatric Treatment (2003), vol. 9. 261
  6. 6. Vealeare elicited and of whether it takes an observer first, getting insight in attentional processes and theperspective. effects of heightened self-focused attention; second, The model may then be used to determine its focusing attention outward in non-threateningpotential application to past and present experi- situations; and third, focusing attention outward inences and how each of the components is linked to threatening situations.a feedback loop. It is particularly important to reviewhow increased self-focused attention and usingsafety behaviours are counterproductive, and Video feedbackincrease the frequency of the thoughts and anxiety. The aim of video feedback is to demonstrate that theOnce a patient is engaged in the model, then various patients’ impressions of how they think they appearstrategies may be used to consolidate understanding are inaccurate and based on their internal imagesand to make changes in the system. and feelings. For example, a patient may make a prediction about how red he appears when heShifting attentional focus blushes. An experiment may be set up, whereby he selects the predicted ‘redness’ on a colour chart andThe aim of shifting attentional focus is to enable compares this with the actual ‘redness’ of hispatients to concentrate on how others respond to blushing on a video with the colour chart in thethem, rather than on constructed images or impres- background. This approach is also suitable for anysions of how they think they appear. A role-play is reaction that can be objectively observed on a videodone, in which the focus of attention is manipulated and compared against an agreed reference order to demonstrate the adverse effect of self-focused attention and safety behaviours. The patientis asked to compare the degree and content of self- Modifying negative self-imagesconsciousness, subjective anxiety and whether the Self-images might be associated with negativeself is still in an observer perspective. memories from childhood or adolescence. For Readers may like to try this for themselves, to begin example, the image and memories might be of beingto understand the strategies used by someone who teased and isolated from one’s peers. Therapy mayis socially anxious. Test out two different scenarios be directed at historical reviews of such imageswith a colleague. For the first scenario, demand a (Arntz & Weertman, 1999), and referring to them ashigh standard from yourself that you must appear being ‘ghosts from the past’ that have not yet beenextremely witty and intelligent in the conversation updated. Therapy is therefore aimed at modifyingwith your colleague and throughout your conver- the images or changing them in line with currentsation, focus your attention on how you are feeling reality.and observe the impression that you think you aremaking (looking at yourself from an observer’sperspective). You should monitor whether you are Modifying assumptions and core beliefscoming across as extremely witty and intelligent.For the second scenario, reduce your expectations Modifying of assumptions and core beliefs in socialabout being witty and intelligent and focus your phobia is no different from that in standard cognitiveattention wholly on the way that your colleague therapy. However, a key strategy is to makeresponds. After the role-play, it is time to receive predictions and test out assumptions in behaviouralfeedback on your performance from your colleague experiments. This may involve ‘exposure’ to socialand reflect on how hard it is to monitor yourself in situations, but it does not involve repeated exposureself-focused attention. Homework might focus on and a model of habituation. The emphasis is onan exercise in dropping of safety behaviours and shifting the focus of attention, dropping safetyshifting attentional focus in a social situation. This behaviours, processing the situation (not the self)might then be followed with more traditional tasks and evaluating what was predicted against whatof graded exposure, but without safety behaviours. actually happened. For example, an individual with Other researchers have developed more elaborate social phobia who fears that she may behave in anstrategies, such as Task Concentration Training unacceptable manner would be encouraged tofor shifting attentional focus (Bogels et al, 1997). This behave ‘unacceptably’, perhaps by making pausesis a technique that aims specifically at redirecting in her speech, having damp armpits, expressing anthe affected individual’s attention away from opinion or spilling her drink, and to observeanxiety and internal sensations such as blushing, another’s response. Alternatively, a survey couldtrembling, sweating or imagery, and towards the be conducted to find how unacceptable thesesocial task at hand and relevant environmental behaviours are to others and what the consequencesaspects. The training consists of three phases: might be.262 Advances in Psychiatric Treatment (2003), vol. 9.
  7. 7. Treatment of social phobiaModifying post-interaction ruminations dose can include sedation, forgetfulness, impaired concentration and disinhibition, especially whenThose affected by social phobia often engage in ‘post- used intermittently. Benzodiazepines are especiallymortems’. Here, the therapist helps the patient to contraindicated for patients with comorbidity ofidentify the content of the event (not the feelings) depression and/or a history of alcohol or substanceand review what actually happened by shifting to misuse.external processing and constructing an alternativedata log of information that is normally disregardedor distorted. Which treatment for whom? Therapy would normally take between 8 and 20out-patient sessions, depending on the severity and Only one trial has compared later versions of CBTchronicity of the phobia. Patients with very severe with an SSRI (Clark et al, 2003), and it found CBT tophobia, who are housebound or dependent on be superior to fluoxetine. No trials have yet com-alcohol, might do better on an intensive programme pared later versions of CBT with a combination ofof CBT as either day-patients or in-patients in the CBT and another SSRI, especially in the long termright setting. and after discontinuation of the active treatment. As always, treatment will depend upon patient choice and availability of therapy, but in commonPharmacotherapy with other anxiety disorders, CBT is the initial choiceMedication is indicated if it is the patient’s first of treatment for social phobia, as it is usually morechoice, CBT has failed, there is a long waiting-list acceptable and has a reduced risk of relapse. Asfor CBT or there is significant comorbidity of always, the main problem is user choice and accessdepression. The treatment of choice in social phobia to CBT in a timely a selective serotonin reuptake inhibitor (SSRI)(Ballenger et al, 1998). Of the SSRIs, only paroxetine Referencesis licensed and marketed in the UK for social phobia, Arntz, A. & Weertman, A. (1999) Treatment of childhoodalthough there is no reason why other SSRIs may memories: theory and practice. Behaviour Research Therapy,not be as effective. Most affected individuals can 37, 715–740. Ballenger, J. C., Davidson, R. T., Lecrubier, Y., et al (1998)tolerate a normal starting dose of an SSRI, as they Consensus statement on social anxiety disorder from thedo not usually experience an ‘activation syndrome’ International Consensus Group on Depression and(as in panic disorder). The starting dose is used for Anxiety. Journal of Clinical Psychiatry, 59, 54–60. Bogels, S. M., Mulkens, S. & De Jong, P. J. (1997) Task2–4 weeks and then increased as necessary. The concentration training and fear of blushing. Clinicalonset of action is usually within 6 weeks and an Psychology and Psychotherapy, 4, 251–258.adequate trial period is 8 weeks. The full response Clark, D. M. (2001) A cognitive perspective on social phobia. In International Handbook of Social Anxiety: Concepts, Researchmay occur after up to 12 weeks. and Interventions Relating to the Self and Shyness (eds W. R. About 50% of patients relapse on discontinuation Crozier & L. E. Alden). pp. 405–430. Chichester: Johnof an SSRI and treatment is therefore continued for a Wiley & Sons. ––– & Wells, A. (1995) A cognitive model of social phobia. Inminimum of 12 months. Once in remission, the dose Social Phobia – Diagnosis, Assessment, and Treatment (eds R.may be reduced slowly (e.g. a 25% reduction every G. Heimberg, M. R. Liebowitz, D. Hope, et al), pp. 69–93.2 months). If a patient fails to respond to an SSRI, New York: Guilford. –––, Ehlers, A., Hackmann, A., et al (2003) Cognitive therapythen some evidence exists for the efficacy of a mono- vs. fluoxetine plus self exposure in the treatment ofamine oxidase inhibitor (MAOI) (e.g. phenelzine, generalized social phobia (social anxiety disorder): A45– 90 mg daily) or a reversible monoamine oxidase randomised placebo controlled trial. Journal of Consulting and Clinical Psychology, in press.inhibitor (RIMA) (e.g. moclobemide, 300–900 mg Connor, K. M., Davidson, J. R. T., Churchill, L. E., et al (2000)daily). Allow 2 weeks between discontinuing an Psychometric properties of the Social Phobia InventorySSRI (5 weeks if fluoxetine) and commencing an (SPIN). British Journal of Psychiatry, 176, 379–386. Davidson, J. R. T., Potts, N. L. S., Richichi, E. A., et al (1991)MAOI or RIMA. Although there are no evidence- The Brief Social Phobia Scale. Journal of Clinical Psychiatry,based guidelines on the treatment of patients who 52, 48–51.have failed to respond fully to an SSRI or an MAOI, Gilbert, P & Andrews, B. (1998) Shame: Interpersonal Behaviour, Psychopathology, and Culture. New York: Oxford Universityexpert opinions suggest the adjunctive use of beta- Press.blockers (e.g. propranolol, starting dose 20 mg daily, Hackmann, A., Clark, D. M. & McManus, F. (2000) Recurrentgradually increased to 60 mg, or atenolol 50–100 mg images and early memories in social phobia. Behaviour Research and Therapy, 38, 601–610.daily) to augment the response. Similarly, clonidine Heimberg, R. G, Dodge, C. S., Hope, D. A., et al (1990)may augment the response for symptoms of blushing Cognitive behavioral group treatment for social phobia:when used as an adjunct to an SSRI. The use of Comparison with a credible placebo control. Cognitive Therapy and Research, 14, 1–23.benzodiazepines (especially short-acting ones) is Liebowitz, M. R. (2002) Social phobia. Modern Problems innot recommended, because side-effects at a higher Pharmacopsychiatry, 22, 141–173.Advances in Psychiatric Treatment (2003), vol. 9. 263
  8. 8. VealeMarks, I. M. & Mathews, A. M. (2002) Brief standard self- c the aim of video feedback is to demonstrate that the rating for phobic participants. Behaviour Research and patient’s impressions of how they think they appear Therapy, 17, 263–267.Salkovskis, P. M. (1991) The importance of behaviour in the are inaccurate and based on internal images and maintenance of anxiety and panic. Behavioural Psycho- feelings therapy, 19, 6–19. d behavioural experiments are used to make predic-Turner, S. M. & Beidel, D. C. (1989) Social phobia: clinical tions which are then tested syndrome, diagnosis, and comorbidity. Clinical Psychology e social skills training is provided. Review, 9 (Special issue: Social phobia), 3–18. 4 In the presentation of social phobia:Further reading a onset is gradual during adolescence b the typical course is chronic and life-longCrozier, W. R. & Alden, L. E. (2001) International Handbook of Social Anxiety: Concepts, Research and Interventions Relating c predisposing factors include a shy or anxious to the Self and Shyness. Chichester: John Wiley & Sons. temperament from childhoodHeimberg, R. G (1995) Social Phobia: Diagnosis, Assessment d a minority are of late onset after a significant life and Treatment. New York: Guilford. event e panic often occurs when alone.Multiple choice questions 5 In pharmacotherapy for social phobia:1 Individuals with social phobia: a an SSRI should usually be commenced at a lowera experience an image from a field perspective (i.e. as dose than that used for depression looking out from their own eyes) b the full response occurs in about 6 weeksb lack social skills c an alternative to an SSRI is an MAOIc avoid social situations to prevent negative evaluation d short-acting benzodiazepines are recommendedd focus on the perceived negative evaluation of a e beta-blockers may be helpful as initial treatment of revealing flaw or unacceptable behaviour choice.e may assume they will be rejected or fail to achieve important goal.2 Social phobia:a is the third most common mental disorder in adultsb has a lifetime prevalence rate of about 10%c occurs more frequently in males than females in psychiatric clinicsd has significant comorbidity with depression, and substance misuse MCQ answerse is more likely to occur among unmarried individuals 1 2 3 4 5 with a lower socio-economic status a F a T a F a T a F3 In cognitive therapy of social phobia: b F b F b F b T b Fa fluoxetine was found to be more effective than CBT c T c F c T c T c Tb the aim of shifting attentional focus is to enable d T d T d T d T d F patients to concentrate on how they think they appear e T e T e F e F e F to others264 Advances in Psychiatric Treatment (2003), vol. 9.